Excluded Drugs List 4-9-20 - AZBlue/media/azblue/files/pharmacy...Page 1 Excluded Drugs List...
Transcript of Excluded Drugs List 4-9-20 - AZBlue/media/azblue/files/pharmacy...Page 1 Excluded Drugs List...
Page 1
Excluded Drugs List Effective 10/1/17*
Date last updated: 4/9/20
Your benefit plan does not cover all drugs. Your benefit plan excludes coverage for drugs with one or more principal ingredients that are already available in greater/lesser strengths and / or combinations. Your plan also excludes drugs that only modify the dosage form (tablet, capsule, liquid, suspension, extended release, tamper resistant) for a drug that is already available in a common dosage form.
The table below lists drugs that are not covered for one of these reasons. The drugs listed in the “Not Covered” column are excluded under your plan. If you use them, you will have to pay the full cost of the drug. BCBSAZ may update and add to this list at any time.
For each excluded drug, we have also listed some alternatives. Any alternatives are subject to normal plan-requirements such as medical necessity. Alternatives are also subject to member cost share requirements such as copayments or coinsurance. Some alternatives may not be covered due to other plan limitations - for example, because the alternative is available over-the counter. If you are currently taking, or have been prescribed, one of these non-covered drugs, talk to your prescriber about whether one of the alternatives would work for you. Be sure to review the Pharmacy Benefit section for Benefit-Specific Exclusions and What is Not Covered in your benefit book for general exclusions and limitations that apply to all benefits.
To check coverage and copay information for a medication under your plan, visit azblue.com and log in to BlueNet. If you do not have access to the website, call the Pharmacy Benefits number on the back of your member ID card.
Therapeutic Class Not Covered Examples of Alternative Options
Analgesics - Anti-Inflammatory Nonsteroidal Anti-Inflammatory Agents (NSAIDs)
ANAPROX DS (Naproxen sodium) tablet 550mg naproxen sodium capsule 220mg (OTC)
DUEXIS (ibuprofen-famotidine) tablet 800-26.6mg ibuprofen tablet 800mg plus famotidine tablet 20mg
fenoprofen capsule 200mg fenoprofen tablet 600mg
fenoprofen capsule 400mg fenoprofen tablet 600mg
FENORTHO (fenoprofen calcium) capsule 200mg fenoprofen tablet 600mg
NALFON (fenoprofen calcium) capsule 200mg fenoprofen tablet 600mg
NALFON (fenoprofen calcium) capsule 400mg fenoprofen tablet 600mg
NAPRELAN CR (naproxen sodium ER) tablet 24-hour 375mg
naproxen DR or EC tablet 375mg
NAPRELAN CR (naproxen sodium ER) tablet 24-hour 500mg
naproxen DR or EC tablet 500mg
NAPRELAN CR (naproxen sodium ER) tablet 24-hour 750mg
naproxen DR or EC tablet 375mg or 500mg
NAPROSYN (naproxen) suspension 125mg/5ml naproxen tablet 250mg or naproxen (OTC)
naproxen suspension 125mg/5ml naproxen tablet 250mg or naproxen (OTC)
naproxen sodium CR tablet 375mg naproxen DR or EC tablet 375mg
naproxen sodium CR tablet 500mg naproxen DR or EC tablet 500mg
naproxen sodium tablet 550mg naproxen sodium capsule 220mg (OTC)
naproxen-esomeprazole magnesium DR tablet 375-20
naproxen DR or EC tablet 375mg plus esomeprazole magnesium tablet 20mg
naproxen-esomeprazole magnesium DR tablet 500-20mg
naproxen DR or EC tablet 500mg plus esomeprazole magnesium DR capsule 20mg
* Effective dates for contract exclusions will vary by plan, and are usually tied to the plan renewal date. If you are currently receiving benefit coverage for any of the non-covered drugs, you will receive a benefit change notice before these exclusions become effective for your plan.
D15112 08/17
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
SPRIX (ketorolac tromethamine) nasal spray 15.75mg-spray
ketorolac tablet 10mg
VIMOVO (naproxen-esomeprazole magnesium) DR tablet 375-20mg
naproxen DR or EC tablet 375mg plus esomeprazole magnesium tablet 20mg
VIMOVO (naproxen-esomeprazole magnesium) DR tablet 500-20mg
naproxen DR or EC tablet 500mg plus esomeprazole magnesium DR capsule 20mg
VIVLODEX (meloxicam) capsule 10mg meloxicam tablet 7.5mg or 15mg
VIVLODEX (meloxicam) capsule 5mg meloxicam tablet 7.5mg or 15mg
ZIPSOR (diclofenac potassium) capsule 25mg diclofenac potassium tablet 50mg or diclofenac sodium DR tablet 50mg
ZORVOLEX (diclofenac) capsule 18mg diclofenac potassium tablet 50mg or diclofenac sodium DR tablet 50mg
ZORVOLEX (diclofenac) capsule 35mg diclofenac potassium tablet 50mg or diclofenac sodium DR tablet 50mg
QMIIZ ODT (meloxicam) orally disintegrating tablet 7.5mg
meloxicam (non-orally disintegrating) tablet
QMIIZ ODT (meloxicam) orally disintegrating tablet 15mg
meloxicam (non-orally disintegrating) tablet
Analgesics - Nonnarcotic Analgesic Combinations ALLZITAL (butalbital-acetaminophen) tablet 25-
325mg butalbital-acetaminophen tablet 50-325mg
BUPAP (butalbital-acetaminophen) tablet 50-300mg
butalbital-acetaminophen tablet 50-325mg
butalbital-acetaminophen tablet 50mg-300mg butalbital-acetaminophen tablet 50-325mg
butalbital-acetaminophen capsule 50mg-300mg butalbital-acetaminophen tablet 50-325mg
VANATOL LQ (butalbital-acetaminophen-caffeine) solution 50-325-40mg/15ml
butalbital-acetaminophen-caffeine tablet 50-325-40mg
VANATOL S (butalbital-acetaminophen-caffeine) solution 50-325-40mg/15ml
butalbital-acetaminophen-caffeine tablet 50-325-40mg
Analgesics - Opioid Opioid Agonists ARYMO ER (morphine sulfate) tablet abuse-
deterrent 15mg morphine sulfate CR tablet 15mg
ARYMO ER (morphine sulfate) tablet abuse-deterrent 30mg
morphine sulfate ER capsule 24-hour 30mg or morphine sulfate CR tablet 30mg
ARYMO ER (morphine sulfate) tablet abuse-deterrent 60mg
morphine sulfate ER capsule 24-hour 60mg or morphine sulfate CR tablet 60mg
CONZIP (tramadol hcl ER) capsule 24-hour biphasic release 100mg
tramadol hcl ER tablet 24-hour biphasic release 100mg
CONZIP (tramadol hcl ER) capsule 24-hour biphasic release 200mg
tramadol hcl ER tablet 24-hour biphasic release 200mg
CONZIP (tramadol hcl ER) capsule 24-hour biphasic release 300mg
tramadol hcl ER tablet 24-hour biphasic release 300mg
MORPHABOND ER (morphine sulfate) tablet 12-hour deterrent 15mg
morphine sulfate CR tablet 15mg
MORPHABOND ER (morphine sulfate) tablet 12-hour deterrent 30mg
morphine sulfate ER capsule 24-hour 30mg or morphine sulfate CR tablet 30mg
MORPHABOND ER (morphine sulfate) tablet 12-hour deterrent 60mg
morphine sulfate ER capsule 24-hour 60mg or morphine sulfate CR tablet 60mg
D15112 08/17 Page 2
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
MORPHABOND ER (morphine sulfate) tablet 12-hour deterrent 100mg
morphine sulfate ER capsule 24-hour 100mg or morphine sulfate CR tablet 100mg
tramadol hcl ER capsule biphasic release 100mg tramadol hcl ER tablet 24-hour biphasic release 100mg
tramadol hcl ER capsule biphasic release 150mg tramadol hcl ER tablet 24-hour biphasic release 100mg or 200mg
tramadol hcl ER capsule biphasic release 200mg tramadol hcl ER tablet 24-hour biphasic release 200mg
tramadol hcl ER capsule biphasic release 300mg tramadol hcl ER tablet 24-hour biphasic release 300mg
Opioid Combinations acetaminophen-caffeine-dihydrocodeine bitartrate tablet 325-30-16mg
acetaminophen-codeine tablet 300-30mg
APADAZ (benzhydrocodone hcl-acetaminophen) tablet 4.08-325mg
benzhydrocodone hcl-acetaminophen tablet 4.08-325mg
APADAZ (benzhydrocodone hcl-acetaminophen) tablet 6.12-325mg
benzhydrocodone hcl-acetaminophen tablet 6.12-325mg
APADAZ (benzhydrocodone hcl-acetaminophen) tablet 8.16-325mg
benzhydrocodone hcl-acetaminophen tablet 8.16-325mg
butalbital-acetaminophen-caffeine-codeine capsule 50-300-40-30mg
butalbital-acetaminophen-caffeine-codeine capsule 50-325-40-30mg
DVORAH (acetaminophen-caffeine-dihydrocodeine) tablet 325-30-16mg
acetaminophen-codeine tablet 300-30mg
FIORICET-CODEINE (butalbital-acetaminophen-caffeine-codeine) capsule 50-300-40-30mg
butalbital-acetaminophen-caffeine-codeine capsule 50-325-40-30mg
PANLOR (acetaminophen-caffeine-dihydrocodeine) tablet 325-30-16mg
acetaminophen-codeine tablet 300-30mg
Anorectal Agents
Rectal Steroids hydrocortisone acetate suppository 30mg hydrocortisone acetate rectal suppository 25mg
PROCTOCORT (hydrocortisone acetate) suppository 30mg
hydrocortisone acetate rectal suppository 25mg
Antianginal Agents Nitrates GONITRO (nitroglycerin) sublingual powder
packet 400mcg nitroglycerin sublingual tablet 0.4mg
Antianxiety Agents Benzodiazepines ATIVAN (lorazepam) tablet 0.5mg lorazepam tablet 0.5mg
ATIVAN (lorazepam) tablet 1mg lorazepam tablet 1mg
ATIVAN (lorazepam) tablet 2mg lorazepam tablet 2mg
Antidepressants Miscellaneous APLENZIN (bupropion HBR ER) tablet 24-hour
174mg bupropion hcl ER tablet 24-hour 150mg
APLENZIN (bupropion HBR ER) tablet 24-hour 348mg
bupropion hcl ER tablet 24-hour 300mg
APLENZIN (bupropion HBR ER) tablet 24-hour 522mg
bupropion hcl ER tablet 24-hour 150mg plus bupropion hcl ER tablet 24-hour 300mg
bupropion XL tablet ER 24-hour 450mg bupropion hcl XL tablet 150mg plus bupropion hcl XR tablet 300mg
FORFIVO XL (bupropion XL) tablet ER 24-hour 450mg
bupropion hcl XL tablet 150mg plus bupropion hcl XR tablet 300mg
D15112 08/17 Page 3
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
WELLBUTRIN XL (buproprion HCL ER) tablet 24-hour 150mg
bupropion hcl XL tablet, 150mg or 300mg
WELLBUTRIN XL (buproprion HCL ER) tablet 24-hour 300mg
bupropion hcl XL tablet, 150mg or 300mg
Selective Serotonin Reuptake Inhibitors (SSRIs)
fluoxetine tablet 60mg fluoxetine capsule 20mg x2/day or fluoxetine tablet 20mg x2/day
fluoxetine DR capsule 90mg fluoxetine capsule 20mg x3/day or fluoxetine tablet 20mg x3/day
PEXEVA (paroxetine mesylate) tablet 10mg paroxetine hcl tablet 10mg
PEXEVA (paroxetine mesylate) tablet 20mg paroxetine hcl tablet 20mg
PEXEVA (paroxetine mesylate) tablet 30mg paroxetine hcl tablet 30mg
PEXEVA (paroxetine mesylate) tablet 40mg paroxetine hcl tablet 40mg
Antidiabetics Antidiabetic Combinations DUETACT (pioglitazone hcl-glimepiride) tablet
30-2mg glimepiride tablet 2mg plus pioglitazone hcl tablet 30mg
DUETACT (pioglitazone hcl-glimepiride) tablet 30-4mg
glimepiride tablet 4mg plus pioglitazone hcl tablet 30mg
pioglitazone hcl-glimepiride tablet 30-2mg glimepiride tablet 2mg plus pioglitazone hcl tablet 30mg
pioglitazone hcl-glimepiride tablet 30-4mg glimepiride tablet 4mg plus pioglitazone hcl tablet 30mg
repaglinide-metformin hydrochloride (repaglinide-metformin hcl) tablet 1-500mg
repaglinide tablet 1mg plus metformin tablet 500mg
repaglinide-metformin hydrochloride (repaglinide-metformin hcl) tablet 2-500mg
repaglinide tablet 2mg plus metformin tablet 500mg
Biguanides GLUMETZA (metformin hcl ER) tablet 24-hour modified release 500mg
metformin hcl ER tablet 500mg or 750mg (generic GLUCOPHAGE XR)
GLUMETZA (metformin hcl ER) tablet 24-hour modified release 1000mg
metformin hcl ER tablet 500mg or 750mg (generic GLUCOPHAGE XR)
metformin hcl ER tablet 24-hour modified release tablet 500mg
metformin hcl ER tablet 500mg or 750mg (generic GLUCOPHAGE XR)
metformin hcl ER tablet 24-hour modified release tablet 1000mg
metformin hcl ER tablet 500mg or 750mg (generic GLUCOPHAGE XR)
Diabetic Other
GVOKE PFS (glucagon) subcutaneous solution prefilled syringe 0.5mg/0.1ml
glucagon injection reconstituted solution 1mg or BAQSIMI ONE PACK (glucagon) nasal powder 3mg/dose or BAQSIMI TWO PACK (glucagon) nasal powder 3mg/dose
GVOKE PFS (glucagon) subcutaneous solution prefillled syringe 1mg/0.2ml
glucagon injection reconstituted solution 1mg or BAQSIMI ONE PACK (glucagon) nasal powder 3mg/dose or BAQSIMI TWO PACK (glucagon) nasal powder 3mg/dose
Antihistamines Ethanolamines carbinoxamine maleate tablet 6mg carbinoxamine maleate tablet 4mg
RYVENT (carbinoxamine maleate) tablet 6mg carbinoxamine maleate tablet 4mg
Antihyperlipidemics HMG COA Reductase Inhibitors
FLOLIPID (simvastatin) suspension 20mg/5ml simvastatin tablet 20mg
FLOLIPID (simvastatin) suspension 40mg/5ml simvastatin tablet 40mg Miscellaneous TRIKLO (omega-3-acid ethyl esters) capsule 1gm omega-3-acid capsule 1gm
D15112 08/17 Page 4
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
Anti-Infective Agents
Miscellaneous PRIMSOL (trimethoprim hcl) oral solution 50mg/5ml
trimethoprim tablet 100mg
TRIMPEX (trimethoprim hcl) oral solution 50mg/5ml
trimethoprim tablet 100mg
Antihypertensives Antihypertensive Combinations
DUTOPROL ER (metoprolol succinate ER-hydrochlorothiazide) tablet 24-hour 25-12.5mg
metoprolol ER tablet 25mg plus hydrochlorothiazide tablet 12.5mg
DUTOPROL ER (metoprolol succinate ER-hydrochlorothiazide) tablet 24-hour 50-12.5mg
metoprolol ER tablet 50mg plus hydrochlorothiazide tablet 12.5mg
DUTOPROL ER (metoprolol succinate ER-hydrochlorothiazide) tablet 24-hour 100-12.5mg
metoprolol ER tablet 100mg plus hydrochlorothiazide tablet 12.5mg
metoprolol succinate ER-hydrochlorothiazide tablet 24-hour 25-12.5mg
metoprolol ER tablet 25mg plus hydrochlorothiazide tablet 12.5mg
metoprolol succinate ER-hydrochlorothiazide tablet 24-hour 50-12.5mg
metoprolol ER tablet 50mg plus hydrochlorothiazide tablet 12.5mg
metoprolol succinate ER-hydrochlorothiazide tablet 24-hour 100-12.5mg
metoprolol ER tablet 100mg plus hydrochlorothiazide tablet 12.5mg
PRESTALIA (perindopril arginine-amlodipine besylate) tablet 3.5-2.5mg
perindopril erbumine tablet 2mg, 4mg, or 8mg plus amlodipine besylate tablet 2.5mg
PRESTALIA (perindopril arginine-amlodipine besylate) tablet 7-5mg
perindopril erbumine tablet 2mg, 4mg, or 8mg plus amlodipine besylate tablet 5mg
PRESTALIA (perindopril arginine-amlodipine besylate) tablet 14-10mg
perindopril erbumine tablet 2mg, 4mg, or 8mg plus amlodipine besylate tablet 10mg
Antimuscarnics Antispasmodics glycopyrrolate tablet 1.5mg glycopyrrolate tablet 1mg and/or 2mg
Antiparkinson Agents Monoamine Oxidase Inhibitors
ZELAPAR (selegiline hcl) orally disintegrating tablet 1.25mg
selegiline hcl capsule 5mg or selegiline hcl tablet 5mg
Attention-Deficit Hyperactivity Disorder Amphetamines ZENZEDI (dextroamphetamine sulfate) tablet
15mg ZENZEDI (dextroamphetamine sulfate) tablet 5mg or 10mg
ZENZEDI (dextroamphetamine sulfate) tablet 2.5mg
ZENZEDI (dextroamphetamine sulfate) tablet 5mg or 10mg
ZENZEDI (dextroamphetamine sulfate) tablet 20mg
ZENZEDI (dextroamphetamine sulfate) tablet 5mg or 10mg
ZENZEDI (dextroamphetamine sulfate) tablet 30mg
ZENZEDI (dextroamphetamine sulfate) tablet 5mg or 10mg
ZENZEDI (dextroamphetamine sulfate) tablet 7.5mg
ZENZEDI (dextroamphetamine sulfate) tablet 5mg or 10mg
Attention-Deficit Hyperactivity Disorder (ADHD) Agents
KAPVAY (clonidine hcl) tablet ER 12-hour 0.1mg clonidine hcl ER tablet 12-hour 0.1mg
Stimulants- Miscellaneous CONCERTA (methylphenidate hcl) tablet osmotic release 18mg
methylphenidate hcl tablet osmotic release 18mg
CONCERTA (methylphenidate hcl) tablet osmotic release 27mg
methylphenidate hcl tablet osmotic release 27mg
CONCERTA (methylphenidate hcl) tablet osmotic release 36mg
methylphenidate hcl tablet osmotic release 36mg
D15112 08/17 Page 5
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
CONCERTA (methylphenidate hcl) tablet osmotic release 54mg
methylphenidate hcl tablet osmotic release 54mg
methylphenidate hcl tablet osmotic release 72mg methylphenidate hcl tablet osmotic release 36mg
RELEXXI (methylphenidate hcl) tablet osmotic release 72mg
methylphenidate hcl tablet osmotic release 36mg
Beta Blockers Non-Selective INDERAL LA (propranolol hcl) capsule ER 24-
hour 60mg propranolol hcl ER capsule 24-hour 60mg
INDERAL LA (propranolol hcl) capsule ER 24-hour 120mg
propranolol hcl ER capsule 24-hour 120mg
INDERAL LA (propranolol hcl) capsule ER 24-hour 160mg
propranolol hcl ER capsule 24-hour 160mg
INDERAL LA (propranolol hcl) capsule ER 24-hour 80mg
propranolol hcl ER capsule 24-hour 80mg
INDERAL XL (propranolol hcl) beads capsule ER 24-hour 120mg
propranolol hcl ER capsule 24-hour 120mg
INDERAL XL (propranolol hcl) beads capsule ER 24-hour 80mg
propranolol hcl ER capsule 24-hour 80mg
INNOPRAN XL (propranolol hcl) beads capsule ER 24-hour 120mg
propranolol hcl ER capsule 24-hour 120mg
INNOPRAN XL (propranolol hcl) beads capsule ER 24-hour 80mg
propranolol hcl ER capsule 24-hour 80mg
Cardiovascular Agents Cardiovascular Combinations
amlodipine besylate-atorvastatin calcium tablet 2.5-10mg
amlodipine besylate tablet 2.5mg plus atorvastatin calcium tablet 10mg
amlodipine besylate-atorvastatin calcium tablet 2.5-20mg
amlodipine besylate tablet 2.5mg plus atorvastatin calcium tablet 20mg
amlodipine besylate-atorvastatin calcium tablet 2.5-40mg
amlodipine besylate tablet 2.5mg plus atorvastatin calcium tablet 40mg
amlodipine besylate-atorvastatin calcium tablet 5-10mg
amlodipine besylate tablet 5mg plus atorvastatin calcium tablet 10mg
amlodipine besylate-atorvastatin calcium tablet 5-20mg
amlodipine besylate tablet 5mg plus atorvastatin calcium tablet 20mg
amlodipine besylate-atorvastatin calcium tablet 5-40mg
amlodipine besylate tablet 5mg plus atorvastatin calcium tablet 40mg
amlodipine besylate-atorvastatin calcium tablet 5-80mg
amlodipine besylate tablet 5mg plus atorvastatin calcium tablet 80mg
amlodipine besylate-atorvastatin calcium tablet 10-10mg
amlodipine besylate tablet 10mg plus atorvastatin calcium tablet 10mg
amlodipine besylate-atorvastatin calcium tablet 10-20mg
amlodipine besylate tablet 10mg plus atorvastatin calcium tablet 20mg
amlodipine besylate-atorvastatin calcium tablet 10-40mg
amlodipine besylate tablet 10mg plus atorvastatin calcium tablet 40mg
amlodipine besylate-atorvastatin calcium tablet 10-80mg
amlodipine besylate tablet 10mg plus atorvastatin calcium tablet 80mg
CADUET (amlodipine besylate-atorvastatin calcium) tablet 5-10mg
amlodipine besylate tablet 5mg plus atorvastatin calcium tablet 10mg
D15112 08/17 Page 6
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
CADUET (amlodipine besylate-atorvastatin calcium) tablet 5-20mg
amlodipine besylate tablet 5mg plus atorvastatin calcium tablet 20mg
CADUET (amlodipine besylate-atorvastatin calcium) tablet 5-40mg
amlodipine besylate tablet 5mg plus atorvastatin calcium tablet 40mg
CADUET (amlodipine besylate-atorvastatin calcium) tablet 5-80mg
amlodipine besylate tablet 5mg plus atorvastatin calcium tablet 80mg
CADUET (amlodipine besylate-atorvastatin calcium) tablet 10-10mg
amlodipine besylate tablet 10mg plus atorvastatin calcium tablet 10mg
CADUET (amlodipine besylate-atorvastatin calcium) tablet 10-20mg
amlodipine besylate tablet 10mg plus atorvastatin calcium tablet 20mg
Cephalosporins
Cephalosporins cephalexin capsule 750mg
cephalexin capsule 250mg plus cephalexin capsule 500mg
DAXBIA capsule 333mg cephalexin capsule 250mg or cephalexin capsule 500mg
KEFLEX capsule 750mg cephalexin capsule 250mg plus cephalexin capsule 500mg
Corticosteroids Glucocorticosteroids RAYOS (prednisone) DR tablet 1mg prednisone tablet 1mg
RAYOS (prednisone) DR tablet 2mg prednisone tablet 1mg or 2.5mg
RAYOS (prednisone) DR tablet 5mg prednisone tablet 5mg
Cough/Cold/Allergy Antitussives
benzonatate capsule 150mg benzonatate capsule 100mg or benzonatate capsule 200mg
Combinations TUSSICAPS (hydrocodone polistirex-chlorpheniramine polistirex) capsule ER 12-hour 5-4mg
hydrocodone polistirex-chlorpheniramine polistirex ER suspension 10-8mg/5ml
TUSSICAPS (hydrocodone polistirex-chlorpheniramine polistirex) capsule ER 12-hour 10-8mg
hydrocodone polistirex-chlorpheniramine polistirex ER suspension 10-8mg/5ml
TUXARIN ER (codeine phos-chlorpheniramine maleate) tablet 12-hour 54.3-8mg
codeine sulfate tablet 60mg plus chlorpheniramine (OTC)
TUZISTRA XR (codeine polistirex-chlorpheniramine polistirex) suspension 14.7-2.8mg/5ml
LEXUSS 210 (chlorpheniramine w/ codeine) liquid 2-10mg/5ml
Dermatologicals Acne Products
ABSORICA (isotretinoin) capsule 10mg AMNESTEEM, CLARAVIS, isotretinoin, MYORISAN or ZENATANE
ABSORICA (isotretinoin) capsule 20mg AMNESTEEM, CLARAVIS, isotretinoin, MYORISAN or ZENATANE
ABSORICA (isotretinoin) capsule 25mg AMNESTEEM, CLARAVIS, isotretinoin, MYORISAN or ZENATANE
ABSORICA (isotretinoin) capsule 30mg AMNESTEEM, CLARAVIS, isotretinoin, MYORISAN or ZENATANE
ABSORICA (isotretinoin) capsule 35mg AMNESTEEM, CLARAVIS, isotretinoin, MYORISAN or ZENATANE
ABSORICA (isotretinoin) capsule 40mg AMNESTEEM, CLARAVIS, isotretinoin, MYORISAN or ZENATANE
D15112 08/17 Page 7
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
ABSORICA LD (isotretinoin micronized) capsule 8mg
AMNESTEEM, CLARAVIS, isotretinoin, MYORISAN or ZENATANE
ABSORICA LD (isotretinoin micronized) capsule 16mg
AMNESTEEM, CLARAVIS, isotretinoin, MYORISAN or ZENATANE
ABSORICA LD (isotretinoin micronized) capsule 24mg
AMNESTEEM, CLARAVIS, isotretinoin, MYORISAN or ZENATANE
ABSORICA LD (isotretinoin micronized) capsule 32mg
AMNESTEEM, CLARAVIS, isotretinoin, MYORISAN or ZENATANE
ACANYA (clindamycin phosphate-benzoyl peroxide) gel 1.2-2.5%
clindamycin phosphate gel 1% plus benzoyl peroxide gel 2.5%
adapalene gel 0.3% adapalene gel 0.1%
adapalene lotion 0.1% adapalene gel 0.1%
adapalene pad 0.1% swab DIFFERIN (adapalene) gel 0.1% (OTC)
adapalene-benzoyl peroxide gel 0.1-2.5% adapalene gel 0.1% plus benzoyl peroxide gel 2.5%
AKTIPAK (benzoyl peroxide-erythromycin) gel pack 5-3%
benzoyl peroxide gel 5% (OTC) plus erythromycin gel
ATRALIN (tretinoin) gel 0.05% tretinoin gel 0.05%
AVAR-E LS (sulfacetamide sodium with sulfur) cream 10-2%
sulfacetamide sodium lotion 10% (acne) with OTC acne sulfur lotion
AVITA (tretinoin) cream 0.025% tretinoin cream 0.025%
AVITA (tretinoin) gel 0.025% tretinoin gel 0.025%
BENZACLIN (clindamycin phosphate-benzoyl peroxide) gel 1-5%
clindamycin phosphate gel 1% plus benzoyl peroxide gel 5%
benzoyl peroxide gel 6.5% benzoyl peroxide gel 5% (OTC) or OC8 gel 7% (OTC)
CLEOCIN-T (clindamycin phosphate) gel 1% clindamycin phosphate gel 1%
CLEOCIN-T (clindamycin phosphate) lotion 1% clindamycin phosphate lotion 1%
CLEOCIN-T (clindamycin phosphate) solution 1% clindamycin phosphate solution 1%
CLEOCIN-T (clindamycin phosphate) swab 1% clindamycin phosphate swab 1%
CLINDAGEL (clindamycin phosphate) gel 1% clindamycin phosphate gel 1%
clindamycin phosphate-benzoyl peroxide gel 1.2-2.5%
clindamycin phosphate gel 1% plus benzoyl peroxide gel 2.5%
clindamycin phosphate-tretinoin gel 1.2-0.025% clindamycin phosphate gel 1% plus tretinoin gel 0.25%
clindamycin phosphate-benzoyl peroxide gel 1.2-5%
clindamycin phosphate gel 1% plus benzoyl peroxide gel 5%
DIFFERIN (adapalene) cream 0.1% adapalene gel 0.1%
DIFFERIN (adapalene) gel 0.1% adapalene gel 0.1%
DIFFERIN (adapalene) gel 0.3% adapalene gel 0.1%
DIFFERIN (adapalene) lotion 0.1% adapalene gel 0.1%
DUAC (clindamycin phosphate-benzoyl peroxide) gel 1.2 (1)-5%
clindamycin phosphate gel 1% plus benzoyl peroxide gel 5%
EPIDUO (adapalene-benzoyl peroxide) gel 0.1-2.5%
adapalene gel 0.1% plus benzoyl peroxide gel 2.5%
EPIDUO FORTE (adapalene-benzoyl peroxide) gel 0.3-2.5%
adapalene gel 0.3% (OTC) plus benzoyl peroxide gel 2.5%
EVOCLIN (clindamycin phosphate) foam 1% clindamycin phosphate foam 1%
D15112 08/17 Page 8
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
FABIOR (tazarotene) foam 0.1% tazarotene cream 0.1%
KLARON (sulfacetamide sodium) lotion 10% sulfacetamide sodium lotion 10% (acne)
NEUAC (clindamycin phosphate-benzoyl peroxide) gel 1.2 (1)-5%
clindamycin phosphate gel 1% plus benzoyl peroxide gel 5%
ONEXTON (clindamycin phosphate-benzoyl peroxide) gel 1.2-3.75%
clindamycin phosphate gel 1% plus benzoyl peroxide gel 5%
PLEXION (sulfacetamide sodium-sulfur) cleansing cloth 9.8-4.8%
sulfacetamide sodium lotion 10% (acne)
PLEXION (sulfacetamide sodium-sulfur) cream 9.8-4.8%
sulfacetamide sodium lotion 10% (acne)
PLEXION (sulfacetamide sodium-sulfur) liquid cleanser 9.8-4.8%
sulfacetamide sodium lotion 10% (acne)
PLEXION (sulfacetamide sodium-sulfur) lotion 9.8-4.8%
sulfacetamide sodium lotion 10% (acne)
RETIN-A (tretinoin) cream 0.025% tretinoin cream 0.025%
RETIN-A (tretinoin) cream 0.05% tretinoin cream 0.05%
RETIN-A (tretinoin) cream 0.1% tretinoin cream 0.1%
RETIN-A (tretinoin) gel 0.025% tretinoin gel 0.025%
RETIN-A (tretinoin) gel 0.1% tretinoin gel 0.1% RETIN-A MICRO (tretinoin) microsphere gel 0.04%
tretinoin gel 0.04%
RETIN-A MICRO (tretinoin) microsphere gel 0.1% tretinoin gel 0.1%
RETIN-A MICRO PUMP (tretinoin) microsphere gel 0.08%
tretinoin gel 0.025%, 0.04%, 0.05%, or 0.1%
sodium sulfacetamide-sulfur cleansing pad 10-4% ZENCIA (sulfacetamide sodium-sulfur) 9-4% liquid wash
sodium sulfacetamide-sulfur liquid wash 9-4% ZENCIA (sulfacetamide sodium-sulfur) 9-4% liquid wash
sodium sulfacetamide-sulfur suspension 8-4% sodium sulfacetamide-sulfur wash 9-4.5%
sulfacetamide sodium-sulfur cream 9.8-4.8% sulfacetamide sodium lotion 10% (acne)
sulfacetamide sodium-sulfur cream 10-2% sulfacetamide sodium lotion 10% (acne) with OTC acne sulfur lotion
sulfacetamide sodium-sulfur liquid cleanser 9.8-4.8%
sulfacetamide sodium lotion 10% (acne)
sulfacetamide sodium-sulfur lotion 9.8-4.8% sulfacetamide sodium lotion 10% (acne)
sulfacleanse suspension 8-4% sodium sulfacetamide-sulfur wash 9-4.5%
SUMADAN WASH (sulfacetamide sodium-sulfur) wash 9-4.5%
sodium sulfacetamide-sulfur wash 9-4.5%
SUMAXIN (sulfacetamide sodium-sulfur) cleansing pad 10-4%
ZENCIA (sulfacetamide sodium-sulfur) 9-4% liquid wash
SUMAXIN (sulfacetamide sodium-sulfur) liquid wash 9-4%
ZENCIA (sulfacetamide sodium-sulfur) 9-4% liquid wash
SUMAXIN TS (sulfacetamide sodium-sulfur) suspension 8-4%
sodium sulfacetamide-sulfur wash 9-4.5%
TRETIN-X (tretinoin) cream 0.0375% tretinoin cream 0.05%
TRETIN-X (tretinoin) cream 0.075% tretinoin cream 0.1%
VELTIN (clindamycin phosphate-tretinoin) gel 1.2-0.025%
clindamycin phosphate gel 1% plus tretinoin gel 0.25%
D15112 08/17 Page 9
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
ZIANA (clindamycin phosphate-tretinoin) gel 1.2-0.025%
clindamycin phosphate gel 1% plus tretinoin gel 0.25%
Antibiotics - Topical mupirocin cream 2% mupirocin ointment 2%
NEO-SYNALAR (neomycin sulfate-fluocinolone acetonide) cream 0.5-0.025%
neomycin-bacitracin-polymyxin ointment plus fluocinonide ointment 0.05%
Antifungal-Topical Azoles EXTINA (ketoconazole) foam 2%
ketoconazole cream 2% or ketoconazole shampoo 2%
ketoconazole aerosol foam 2% ketoconazole cream 2% or ketoconazole shampoo 2%
KETODAN (ketoconazole) foam 2% ketoconazole cream 2% or ketoconazole shampoo 2%
luliconazole cream 1% clotrimazole cream 1%
LUZU (luliconazole) cream clotrimazole cream 1%
OXISTAT (oxiconazole nitrate) lotion 1% oxiconazole cream 1%
XOLEGEL (ketoconazole) gel 2% ketoconazole cream 2% or ketoconazole shampoo 2%
Anti-Inflammatory Agents - Topical PENNSAID (diclofenac sodium) solution 2% diclofenac sodium solution 1.5%
Corticosteroids - Topical DESOWEN (desonide) cream 0.05% desonide cream 0.05%
desoximetasone ointment 0.05% desoximetasone ointment 0.25%
desoximetasone spray 0.25% desoximetasone ointment 0.25%
DUOBRII (halobetasol propionate-tazarotene) lotion 0.01-0.045%
TAZORAC (tazarotene) plus halobetasol
ENSTILAR (calcipotriene-betamethasone dipropionate) foam 0.005-0.064%
calcipotriene cream 0.005% plus betamethasone dipropionate cream 0.05%
fluocinonide cream 0.1% fluocinonide cream 0.05%
halobetasol propionate foam 0.05% halobetasol ointment 0.05% or halobetasol cream 0.05%
hydrocortisone butyrate cream 0.1% hydrocortisone butyrate solution 0.1% or hydrocortisone butyrate lotion 0.1%
IMPOYZ (clobetasol propionate) 0.025% clobetasol propionate cream 0.05%
LEXETTE (halobetasol propionate) foam 0.05% halobetasol ointment 0.05% or halobetasol cream 0.05%
LOCOID LIPOCREAM (hydrocortisone butyrate hydrophilic lipo base) cream 0.1%
hydrocortisone butyrate solution 0.1% or hydrocortisone butyrate lotion 0.1%
SYNALAR (fluocinolone acetonide) solution 0.01%
fluocinolone acetonide solution 0.01% or fluocinonide cream 0.05%
TOPICORT (desoximetasone) ointment 0.05% desoximetasone ointment 0.25%
TOPICORT (desoximetasone) spray 0.25% desoximetasone ointment 0.25%
TRIDESILON (desonide) cream 0.05% desonide cream 0.05%
ULTRAVATE (halobetasol propionate) cream 0.05%
halobetasol ointment 0.05% or halobetasol cream 0.05%
ULTRAVATE (halobetasol propionate) lotion 0.05%
halobetasol ointment 0.05% or halobetasol cream 0.05%
ULTRAVATE (halobetasol propionate) ointment 0.05%
halobetasol ointment 0.05% or halobetasol cream 0.05%
VANOS (fluocinonide) cream 0.1% fluocinonide cream 0.05%
D15112 08/17 Page 10
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
Immunomodulating Agents-Topical
imiquimod cream 3.75% imiquimod cream 5%
ZYCLARA (imiquimod) cream 3.75% imiquimod cream 5%
ZYCLARA PUMP (imiquimod) cream 2.5% imiquimod cream 5%
ZYCLARA PUMP (imiquimod) cream 3.75% imiquimod cream 5% Local Anesthetics - Topical lidocaine and tetracaine cream 7-7% aspercreme 4% or lidocaine cream 4%, 5%
PLIAGLIS (lidocaine-tetracaine) cream 7-7% aspercreme 4% or lidocaine cream 4%, 5%
SYNERA (lidocaine-tetracaine) topical patch 70-70mg
lidocaine-prilocaine cream 2.5-2.5%
ZTLIDO PAD (lidocaine) patch 1.8% lidocaine cream 2% Rosacea Agents doxycycline DR capsule 40mg doxycycline hyclate tablet 20mg
METROCREAM (metronidazole) cream 0.75% metronidazole cream 0.75%
METROGEL (metronidazole) gel 1% metronidazole gel 1%
METROLOTION (metronidazole) lotion 0.75% metronidazole lotion 0.75%
NORITATE (metronidazole) cream 1% metronidazole lotion 0.75%
ORACEA (doxycycline) DR capsule 40mg doxycycline hyclate tablet 20mg
Diuretics Potassium Sparing Diuretics
CAROSPIR (spironolactone) oral suspension 25mg/5ml
spironolactone tablet 25mg
Endocrine and Metabolic Bone Density Regulators ATELVIA (risedronate sodium) DR tablet 35mg alendronate sodium tablet 70mg
BINOSTO (alendronate sodium effervescent) tablet 70mg
alendronate sodium tablet 70mg
FOSAMAX + D (alendronate sodium-cholecalciferol) tablet 70-2800mg-unit
alendronate sodium tablet 70mg plus vitamin d-3 (cholecalciferol) tablet 2000unit
FOSAMAX + D (alendronate sodium-cholecalciferol) tablet 70-5600mg-unit
alendronate sodium tablet 70mg plus vitamin d-3 (cholecalciferol) tablet 5000unit
risedronate sodium DR tablet 35mg alendronate sodium tablet 70mg Estrogens
Estrogen Combinations BIJUVA (estradiol-progesterone) capsule 1-100mg
progesterone micronized capsule 100mg plus estradiol 1mg
Heavy Metal Antagonists Chelating Agents CUPRIMINE (penicillamine) capsule 250mg DEPEN TITRA (penicillamine) tablets 250mg
penicillamine capsules 250mg DEPEN TITRA (penicillamine) tablets 250mg
Hematologicals Platelet Aggregation Inhibitors
aspirin/omeprazole (aspirin-omeprazole) DR tablet 325-40mg
aspirin DR tablet 325mg plus omeprazole DR capsule 40mg
YOSPRALA (aspirin-omeprazole) DR tablet 325-40mg
aspirin DR tablet 325mg plus omeprazole DR capsule 40mg
YOSPRALA (aspirin-omeprazole) DR tablet 81-40mg
aspirin DR tablet 81mg plus omeprazole DR capsule 40mg
aspirin-omeprazole (aspirin-omeprazole) DR tablet 81-40mg
aspirin DR tablet 81mg plus omeprazole DR capsule 40mg
Hematopoietic Agents Agents For Sickle Cell Anemia
ENDARI (glutamine) powder pack 5gm glutamine powder packet (OTC), glutamine capsule 500mg (OTC) or L-glutamine tablet 500mg (OTC)
D15112 08/17 Page 11
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
Hypnotics/Sedatives/Sleep Disorder Non-Barbiturate Hypnotics EDLUAR (zolpidem tartrate) sublingual tablet
10mg zolpidem tartrate tablet 10mg
EDLUAR (zolpidem tartrate) sublingual tablet 5mg
zolpidem tartrate tablet 5mg
INTERMEZZO (zolpidem tartrate) sublingual tablet 1.75mg
zolpidem tartrate tablet 5mg
INTERMEZZO (zolpidem tartrate) sublingual tablet 3.5mg
zolpidem tartrate tablet 5mg
zolpidem tartrate sublingual tablet 1.75mg zolpidem tartrate tablet 5mg
zolpidem tartrate sublingual tablet 3.5mg zolpidem tartrate tablet 5mg ZOLPIMIST (zolpidem tartrate) oral spray 5mg/act
zolpidem tartrate tablet 5mg
Migraine Products Migraine Combinations sumatriptan-naproxen sodium (sumatriptan-
naproxen sodium) tablet 85-500mg sumatriptan succinate tablet 50mg or 100mg plus naproxen tablet 500mg
TREXIMET (sumatriptan-naproxen sodium) tablet 10-60mg
sumatriptan succinate tablet 25mg plus naproxen tablet 250mg
TREXIMET (sumatriptan-naproxen sodium) tablet 85-500mg
sumatriptan succinate tablet 50mg or 100mg plus naproxen tablet 500mg
Migraine Products D.H.E. 45 (dihydroergotamine mesylate) injection 1mg/ml
dihydroergotamine mesylate injection 1mg/ml
NSAIDS CAMBIA (diclofenac potassium) packet 50mg diclofenac potassium tablet 50mg Serotonin Agonists FROVA (frovatriptan succinate) tablet 2.5mg frovatriptan succinate tablet 2.5mg
ONZETRA XSAIL (sumatriptan succinate) exhaler powder 11mg
sumatriptan succinate tablet 25mg
ZEMBRACE SYMTOUCH (sumatriptan succinate) solution auto-injector 3mg/0.5ml
sumatriptan succinate injection 4mg/0.5ml
Musculoskeletal Therapy Central Muscle Relaxants AMRIX (cyclobenzaprine hcl) capsule ER 24-hour
15mg cyclobenzaprine hcl tablet 5mg or 10mg
AMRIX (cyclobenzaprine hcl) capsule ER 24-hour 30mg
cyclobenzaprine hcl tablet 5mg or 10mg
carisoprodol tablet 250mg carisoprodol tablet 350mg
chlorzoxazone tablet 250mg chlorzoxazone tablet 500mg
cyclobenzaprine hcl tablet 7.5mg cyclobenzaprine hcl tablet 5mg or 10mg
SOMA (carisoprodol) tablet 250mg carisoprodol tablet 350mg
tizanidine capsule 2mg tizanidine tablet 2mg
tizanidine capsule 4mg tizanidine tablet 4mg
tizanidine capsule 6mg tizanidine tablet 2mg plus 4mg
Neuromuscular Agents ALS Agents/Benzathiazoles RILUTEK (riluzole) tablet 50mg riluzole tablet 50mg
Nasal Agents
D15112 08/17 Page 12
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
Nasal Steroids
XHANCE (fluticasone propionate) nasal exhaler suspension 93 mcg/act
FLONASE Allergy Relief (fluticasone propionate) nasal suspension 50 mcg/act (OTC) or goodsense nasoflow (fluticasone propionate) nasal suspension 50 mcg/act (OTC)
Ophthalmic Agents Beta-Blockers BETIMOL (timolol) ophthalmic solution 0.25% timolol maleate ophthalmic solution 0.25%
BETIMOL (timolol) ophthalmic solution 0.5% timolol maleate ophthalmic solution 0.5% Prostaglandin Analogs XALATAN (latanoprost) ophthalmic solution
0.005% latanoprost ophthalmic solution 0.005%.
Psychotherapeutic and Neurological Postherpetic Neuralgia (PHN)
GRALISE (gabapentin) tablet 300mg gabapentin capsule 300mg
GRALISE (gabapentin) tablet 600mg gabapentin tablet 600mg
GRALISE STARTER MIS (gabapentin) 300/600mg
gabapentin capsule 300mg plus gabapentin tablet 600mg
Restless Leg Syndrome (RLS)
HORIZANT (gabapentin enacarbil) CR tablet 300mg
gabapentin capsule 300mg
HORIZANT (gabapentin enacarbil) CR tablet 600mg
gabapentin tablet 600mg
Vasomotor Symptom BRISDELLE (paroxetine mesylate) capsule 7.5mg
paroxetine tablet 10mg
paroxetine mesylate capsule 7.5mg paroxetine tablet 10mg
Tetracyclines Tetracyclines ACTICLATE (doxycycline hyclate) tablet 75mg doxycycline hyclate capsule 50mg
ACTICLATE (doxycycline hyclate) tablet 150mg doxycycline hyclate capsule 50mg plus doxycycline hyclate capsule 100mg
COREMINO (minocycline hcl) tablet ER 24-hour 45mg
minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg
COREMINO (minocycline hcl ER) tablet 90mg minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg
COREMINO (minocycline hcl ER) tablet 135mg minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg
DORYX (doxycycline hyclate) DR tablet 50mg doxycycline hyclate capsule 50mg
DORYX (doxycycline hyclate) DR tablet 200mg doxycycline hyclate DR tablet 100mg
DORYX MPC (doxycycline hyclate) DR tablet 120mg
doxycycline hyclate DR tablet 100mg
doxycycline hyclate tablet 50mg doxycycline hyclate tablet 20mg or capsule 50mg
doxycycline hyclate tablet 75mg doxycycline hyclate capsule 50mg
doxycycline hyclate tablet 80mg doxycycline hyclate capsule 50mg
doxycycline hyclate tablet 150mg doxycycline hyclate capsule 50mg plus doxycycline hyclate capsule 100mg
doxycycline hyclate DR tablet 50mg doxycycline hyclate capsule 50mg
doxycycline hyclate DR tablet 150mg doxycycline monohydrate capsule 50mg and/or doxycycline monohydrate capsule 100mg
doxycycline hyclate DR tablet 200mg doxycycline hyclate DR tablet 100mg
doxycycline monohydrate capsule 75mg doxycycline monohydrate capsules or tablets
D15112 08/17 Page 13
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
doxycycline monohydrate capsule 150mg doxycycline monohydrate capsules or tablets
minocycline hcl ER tablet 45mg minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg
minocycline hcl ER tablet 90mg minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg
minocycline hcl ER tablet 135mg minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg
MONDOXYNE NL (doxycycline monohydrate) capsule 50mg
doxycycline monohydrate capsules or tablets
MONDOXYNE NL (doxycycline monohydrate) capsule 75mg
doxycycline monohydrate capsules or tablets
MONDOXYNE NL (doxycycline monohydrate) capsule 100mg
doxycycline monohydrate capsules or tablets
MONODOX (doxycycline monohydrate) capsule 75mg
doxycycline monohydrate capsules or tablets
OKEBO (doxycycline monohydrate) capsule 75mg
doxycycline monohydrate capsules or tablets
SOLOXIDE DR oral tablet 150mg doxycycline monohydrate capsule 50mg and/or doxycycline monohydrate capsule 100mg
TARGADOX (doxycycline hyclate) 50mg tablet doxycycline hyclate tablet 20mg or capsule 50mg
XIMINO (minocycline) ER capsule 45mg minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg
XIMINO (minocycline) ER capsule 90mg minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg
XIMINO (minocycline) ER capsule 135mg minocycline hcl capsule 50mg and/or minocycline hcl capsule 75mg and/or minocycline hcl capsule 100mg
Ulcer Proton Pump Inhibitors ACIPHEX (rabeprazole sodium) DR tablet 20mg rabeprazole sodium EC tablet 20mg
ACIPHEX SPRINKLE (rabeprazole sodium) DR capsule 5mg
rabeprazole sodium EC tablet 20mg
ACIPHEX SPRINKLE (rabeprazole sodium) DR capsule 10mg
rabeprazole sodium EC tablet 20mg
esomeprazole strontium DR capsule 24.65mg NEXIUM 24HR capsule 20mg (OTC)
esomeprazole strontium DR capsule 49.3mg NEXIUM 24HR capsule 20mg (OTC) lansoprazole DR tablet dispersible (Solutab) 15mg
lansoprazole DR capsule 15mg
lansoprazole DR tablet dispersible (Solutab) 30mg
lansoprazole DR capsule 30mg
NEXIUM (esomeprazole magnesium) DR capsule 20mg
NEXIUM 24HR capsule 20mg (OTC)
NEXIUM (esomeprazole magnesium) DR capsule 40mg
NEXIUM 24HR capsule 20mg (OTC)
D15112 08/17 Page 14
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
NEXIUM (esomeprazole magnesium) DR suspension 2.5mg
NEXIUM 24HR capsule 20mg (OTC)
NEXIUM (esomeprazole magnesium) DR suspension 5mg
NEXIUM 24HR capsule 20mg (OTC)
NEXIUM (esomeprazole magnesium) DR suspension 10mg
NEXIUM 24HR capsule 20mg (OTC)
NEXIUM (esomeprazole magnesium) DR suspension 20mg
NEXIUM 24HR capsule 20mg (OTC)
NEXIUM (esomeprazole magnesium) DR suspension 40mg
NEXIUM 24HR capsule 20mg (OTC)
PREVACID (lansoprazole) DR capsule 15mg lansoprazole DR capsule 15mg
PREVACID (lansoprazole) DR capsule 30mg lansoprazole DR capsule 30mg
PREVACID (lansoprazole) DR tablet dispersible (solutab)15mg
lansoprazole DR capsule 15mg
PREVACID (lansoprazole) DR tablet dispersible (solutab) 30mg
lansoprazole DR capsule 30mg
PRILOSEC (omeprazole magnesium) DR suspension packet 2.5mg
omeprazole DR capsule 10mg
PRILOSEC (omeprazole magnesium) DR suspension packet 10mg
omeprazole DR capsule 10mg
PROTONIX (pantoprazole sodium) EC tablet 20mg
pantoprazole sodium EC tablet 20mg
PROTONIX (pantoprazole sodium) EC tablet 40mg
pantoprazole sodium EC tablet 40mg
PROTONIX (pantoprazole sodium) DR suspension packet 40mg
pantoprazole sodium EC tablet 40mg
raberazole (rabeprazole sodium) DR capsule 10mg
rabeprazole sodium EC tablet 20mg
Ulcer Therapy Combinations lansoprazole-amoxicillin-clarithromycin therapy
pack
lansoprazole DR capsule 30mg, amoxicillin (trihydrate) capsule 500mg plus clarithromycin 500mg tablets
omeppi (omeprazole-sodium bicarbonate) capsule 20-1100mg
omeprazole DR capsule 20mg
omeppi (omeprazole-sodium bicarbonate) capsule 40-1100mg
omeprazole DR capsule 40mg
omeprazole-sodium bicarbonate capsule 20-1100mg
omeprazole DR capsule 20mg
omeprazole-sodium bicarbonate capsule 40-1100mg
omeprazole DR capsule 40mg
omeprazole-sodium bicarbonate powder pack for suspension 20-1680mg
omeprazole DR capsule 20mg
omeprazole-sodium bicarbonate powder pack for suspension 40-1680mg
omeprazole DR capsule 40mg
PREVPAC (amoxicillin capsule-clarithromycin tablet-lansoprazole capsule DR) therapy pack
lansoprazole DR capsule 30mg, amoxicillin (trihydrate) capsule 500mg plus clarithromycin 500mg tablets
PYLERA (bismuth subcitrate potassium-metronidazole-tetracycline) capsule 140-125-125mg
bismutah chew 262mg (OTC), metronidazole tablet 250mg plus tetracycline capsule 250mg
D15112 08/17 Page 15
Excluded Drugs List Effective 10/1/17*
Date last updated 8/21/19
Therapeutic Class Not Covered Examples of Alternative Options
ZEGERID (omeprazole-sodium bicarbonate) capsule 20-1100mg
omeprazole DR capsule 20mg
ZEGERID (omeprazole-sodium bicarbonate) capsule 40-1100mg
omeprazole DR capsule 40mg
ZEGERID (omeprazole-sodium bicarbonate) powder pack for suspension 20-1680mg
omeprazole DR capsule 20mg
ZEGERID (omeprazole-sodium bicarbonate) powder pack for suspension 40-1680mg
omeprazole DR capsule 40mg
Urinary Antispasmodics Antimuscarinics (Anticholinergic)
DETROL (tolterodine tartrate) tablet 1mg tolterodine tartrate tablet 1mg
DETROL (tolterodine tartrate) tablet 2mg tolterodine tartrate tablet 2mg DETROL LA (tolterodine tartrate) capsule ER 2mg
tolterodine tartrate tablet 2mg
DETROL LA (tolterodine tartrate) capsule ER 4mg
tolterodine tartrate tablet 2mg
DITROPAN XL (oxybutynin chloride) tablet ER 5mg
oxybutynin ER tablet 5mg
DITROPAN XL (oxybutynin chloride) tablet ER 10mg
oxybutynin ER tablet 10mg
DITROPAN XL (oxybutynin chloride) tablet ER 15mg
oxybutynin ER tablet 15mg
GELNIQUE (oxybutynin) gel 10% 1gm box oxybutynin chloride tablet 5mg
GELNIQUE PUMP (oxybutynin) gel 10% 30gm pump bottle
oxybutynin chloride tablet 5mg
tolterodine tartrate capsule ER 2mg tolterodine tartrate tablet 2mg
tolterodine tartrate capsule ER 4mg tolterodine tartrate tablet 2mg
Vaginal Estrogens Estrogens IMVEXXY (estradiol) vaginal insert 4mcg ESTRACE (estradiol) vaginal cream 0.01%
IMVEXXY (estradiol) vaginal insert 10mcg ESTRACE (estradiol) vaginal cream 0.01%
D15112 08/17 Page 16
Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call 602‐864‐4884 for Spanish and 877‐475‐4799 for all other languages and other aids and services.
If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: BCBSAZ’s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ 85002‐3466, 602‐864‐2288, TTY/TDD 602‐864‐4823, [email protected]. You can file a grievance in person or by mail or email. If you need help filing a grievance BCBSAZ’s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1‐800‐368‐1019, 800‐537‐7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Multi-language Interpreter Services Spanish: Si usted, o alguien a quien usted esta ayudando, tiene preguntas acerca de Blue Cross Blue
Shield of Arizona, tiene derecho a obtener ayuda e informacion en su idiioma sin costo alguno. Para hablar con un interprete, llame al 602-864-4884.
Navajo: Dii kwe'e atah nflfnigff Blue Cross Blue Shield of Arizona haada yit'eego bfna'fditkidgo ef doodago Haida blja anilyeedfgfi t'aadoo le'e yfna'fdftkidgo beehaz'aanii hoiQ dff t'aa hazaadk'ehji haka a'doowotgo bee haz'q doo bqqh ilfnfgoo. Ata' halne'fgii kojt' bichT hodiilnih 877-475-4799.
Chinese: :Ml~1~ . ~~1~lEi±t~WJIY-Jf.t~ . ~lm:li'Nili.A.Ifi §IY-J:g~ Blue Cross Blue Shield of Arizona :tJiiii 1¥.1 PQ~~ . 1~~m fiJ ~ ~ J;.J. 1~ ~£}~fi~~$1J ~ llJJ fD~fl,~, o 5ft~- frr ~~~~i ~ . ~~15l~~i5 1":£ tttnfi.A.~::f: 877-475-47990
Vietnamese: Neu quy vi, hay ngU'O'i rna quy vi dang giup do, co cau hoi ve Blue Cross Blue Shield of Arizona quy vise co quyen dU'<;YC giup va co them thong tin bang ngon ngU' cua mlnh mien phi. De n6i chuy~n v6'i mot thong dich vien, xin goi 877-475-4799.
Arabic: ~ J~l ~ 0=JI ~.ili •Blue Cross Blue Shield of Arizona tY'l~ 4.t...,i ~~w ~ <.>-ll _,i dl;-ll 0~ u!
877-475-4799. '-:-l J..-:;1 ~_?. ~ ~~- ;i..ilS:; ~~ 0J.l 0-o ~ ~.JJ~I ~.::A ... _,h.JI_, ~~WI
Tag.alog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue Cross Blue Shield of Arizona, may karapatan ka na makakuha ng tulong at imporma.syon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 877-475-4799.
Korean: eJ-Q{ 71-l o~ EE::: 71-lo~J~ §~ 21.::: 01~ N~OI BlueCrossBiueShieldofA.rizona Oll 21- oH fd ~ ~ 0 I ~ C~ e:! 711 o~::: ~ 2.1 e!- ~ ~ Jll- ~ 5:!. ~ ~I o~ ~ ~ 01 £ tll ~ ~ EJ- lli 0 I ~ ~ -* 21.::: ~2.1J~ 21.~LICL~~Jil ~Q:l N2~ OH J i o~JI ~loHJd::: 877-475-4799~ ~2~0~~1-1 2.
French: Si vous, ou quelqu'un que vous etes en train d'aider, a des questions a propos de Blue Cross Blue Shield of Arizona, vous avez le droit d'obtenir de I' aide et !'information dans votre langue a aucun coOt. Pourparler a un interprete, appelez 877-475-4799.
German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Blue Cross Blue Shield of Arizona haben, haben Sie das Recht, kostenlose Hilfe und lnformationen in lhrer Sprache zu erhalten. Urn mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 877-475-4799 an.
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Serbo-Croatian: Ukoliko Vi iii neko kome Vi pomazete ima pitanje o Blue Cross Blue Shield of Arizona, imate pravo da besplatno dobijete pomoc i informacije na Vasem jeziku .. Da biste razgovarali sa prevodiocem, nazovite 877-475-4799.
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